Visitor Questionnaire

Čeština • Deutsch • English • Español • 日本語 • 한국어 • Nederlands • Svenska • Tiếng Việt

Updated: December 22, 2020

Employee Information Center

COVID-19 (Coronavirus) Visitor Questionnaire

Printer-Friendly Download 135 KB, PDF)

Updated December 14, 2020

Prior to visiting a CoorsTek facility, we request that you complete this questionnaire and provide your responses to your CoorsTek contact.

If you answer yes to any of the questions below, you are requested to reschedule your visit, provide a remote meeting option or send an alternative company representative

1. Have you traveled outside this country in the past 14 days?  
   Yes   No
   
   
2. Have you traveled within this country in the past 14 days to an area that is still under Stay-at-Home Orders outside your region?
   Yes   No
   
   
   • This is subject to local quarantine directives and will be applicable as per local jurisdiction.
   • If there is not a current travel advisory for the region, a Yes response is acceptable.                                                         

3. Do you know if you have been in close contact with anyone diagnosed or presumed positive with COVID-19 in the past 14 days? 
Yes   No

4. Do you currently have a fever or any signs of illness?
Yes    No

Check those that apply:

• Visitors who answer yes to one of these symptoms should reschedule, provide a remote meeting option or send an alternative company representative:

o Fever □

o Fatigue/Weakness □

o Dry cough □

o Shortness of breath or difficulty breathing □

• Visitors who answer yes to 2 or more of these symptoms should reschedule, provide a remote meeting option or send an alternative company representative.

o Chills or shaking with chills □

o Muscle pain or body aches □

o Headache □

o Sore throat □

o Loss of taste or smell □

o Congestion or runny nose □

o Nausea or vomiting □

o Diarrhea □

 

Date: ______________________________________________

Visitor Name: _______________________________________

Company: __________________________________________

CoorsTek Contact: ___________________________________

CoorsTek Facility: ____________________________________